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Stuck in a rut, low supply/supplementing inefficient nurser

This is a long story, so thanks in advance if you get all the way through it!

My little guy was born 7 weeks ago at 41 weeks, 7lbs 5oz. He had a strong suck and seemed to latch well within the first 2 hours of being born (with assistance from nurses for positioning). I had difficulty getting him positioned well and latching, asked for help from nurses fairly often in the 2 1/4 days in the hospital. My milk hadn't come in from what we could tell, I didn't have any changes after delivery. On the day we were going to check out, he had lost 10% of his weight and diaper output was slowed. The pediatrician advised supplementing with formula (via finger/dropper) with the idea that it would get us over the hump until my milk came in fully. At that point we also met with a IBCLC before checking out to work on latching and discuss pumping to stimulate my supply after every feeding. We bought a Medela Advanced Personal Double Electric Pump to take home.

Once home, his first diaper had some orange tinge so he was fairly dehydrated, but after the next dropper feeding and going forward his diapers got on track to where they should be. We had scheduled a follow up with the IBCLC at the hospital Tuesday (discharged Friday). In the meantime, we were nursing then supplementing with formula and pumping each feeding. On Monday, we saw the pediatrician and his weight was definitely improved but they also noticed an issue. He was quite severely tongue tied and the doctor said having it clipped should help with the latch, so we went ahead with that. We worked on the latch and positioning again with the LC but it was still difficult. He has a very short time between giving hunger cues and becoming frantic, so often times he is screaming bloody murder at the breast making latching all the more difficult. Once he did latch, he continued to be very sleepy at the breast and we were constantly needing to coax him into wakefulness to nurse.

In the next LC follow up, I had taken a break from nursing (this would be around week 2) because it was too emotionally taxing and I knew every nursing session ending in tears wasn't good for me or the baby. We continued to supplement but via bottle, and I kept pumping after every feeding. My pumping output did increase a bit, but it was still at half or less of what he needed.

We had two more follow ups with the LC, we found some methods to help with his latch on the right side (football position) and the frantic arm flailing (swaddling). He was still very sleepy at the breast and would nod off after at most a few minutes and become very hard to rouse. We did do weighing before and after feedings each visit, the most he was able to get in the last visit was 1 oz combined after 24 minutes; LC advised to basically assume that's the max he's getting. Our plan was to continue with nursing 1-2 times a day to help stimulate my supply and practice latching with the note that more nursing would help my supply. I was still at the 40% or so BM and 60% formula.

We've been in this rut ever since. With my husband going back to work, it's even more difficult to get in time to nurse every day and now bub is eating less frequently on top of it. It takes him usually a good hour plus to eat and settle down with the bottles, then I need to pump and wash up. Sometimes I'm barely finished with all of that and he's hungry again. During the day he's usually eating every 2-3 hours, going for longer stretches occasionally late afternoon or overnight. I think he's in the midst of a growth spurt right now so he's eating a ton and we've had a sleepless night (later figured out he was just a tad hungry which made him a touch fussy and couldn't sleep longer than 10 minutes but was giving minimal hunger cues).

When nursing right now, I try to give him 15 minutes on each side but he's usually to the very hard to rouse sleep level by about 7 minutes which is definitely an improvement. He is swallowing consistently for longer periods now, but he's still ravenous once he's done nursing. He is a little difficult to read as far as fullness, he screams/shows hunger cues for 5-10 minutes even after a fully supplemented meal. I've tried just letting him sleep on the second side until he wakes up (usually 10-15 minutes) and he's in full-on hunger cue/frantic mode. I am considering making another appointment with the LC to get an idea of how much he's transferring when he does have a good nursing session, but I feel like we're still seeing about that 1 oz at the breast.

I have a fast let down, my right side production is usually half to one quarter of the amount of the left side. I almost always put him to my right side first because it needs a lot more work to extract the milk and I want his best sucking there first. I don't know if that's the best plan to get him the most milk when nursing since he is definitely sleepier once he gets to the left (despite burping and undressing, etc). Currently I am pumping at the least .5oz combined (late evening when it's only been 2 hours between feedings) and at the most 2.25oz (overnight or when it's been ~5 hours between feedings). When I pump after nursing, I get about .25-.5oz on the left side and a similar amount on the right (which is close to what I normally would pump without nursing before). During the day I get about 1.5oz on average. Several times yesterday, I got all of 5mL out of the right side. I have increased my pumping to 20 minutes (previously did 15 based on the LC's advice) because I noticed my right side would give me almost a full third or half more in the last 5 minutes (of the 20). I do have hypothyroidism, fairly mild and my dosage was not adjusted during the pregnancy. My levels went up and down but since they were technically in the "normal" range the PCP didn't want to change it. I went to have it checked 3 weeks ago with the idea it may be affecting my supply but my TSH was quite low (they did not check T3/T4 for whatever reason). I am going to try to get to an endocrinologist in the near future just to make sure the treatment makes sense.

At this point, I am getting burnt out. The days I'm alone are quite arduous since he either needs to be held or wants to play (and I want to play with him!) after eating and it's very difficult to cram in time to pump - let alone nurse to begin with. I usually need to get in a nap or two as well so the time slots I do have some time, I should be sleeping. From what I can tell, the advice seems to be I need to nurse and pump more to increase supply (I did try Motherlove More Milk Plus with no real difference seen). My frustration with nursing is that we'll spend 45 minutes with all the coaxing and still only get a small portion of his feeding in, so we still need to do all of the bottles and settling down after. He has some reflux issues so we also spend about 30 minutes after eating before laying him down if he's going to sleep.

I want to keep giving him the breast milk, whatever I can provide - but it's wearing me down. I'm looking for some hope that there is a light at the end of the tunnel. I feel like the combination of inefficient nursing and low supply is a double whammy, and if we could at least resolve *one* of the issues it would make a big difference. I know his efficiency at nursing is related to supply/stimulation but is there some other way to get my supply up reliably? For the first month, I was pumping 8+ times a day with 1-2 nursing sessions added in and my supply barely crept up. Now I'm pumping around 6 times a day with 1-2 nursing sessions. One of the LCs did suggest renting a hospital grade pump to help with stimulation, I am a bit reluctant to go ahead with that because it would be kind of pricey over the long term - not sure how long I would need to give it to determine if it was going to help with the supply or not.

Thank you again for taking the time to read all of this and I'd appreciate any insight or comments.

Re: Stuck in a rut, low supply/supplementing inefficient nur

Welcome to the forum and congratulations on the baby and on making it this far despite a lot of significant challenges.

I'd be really curious to see what would happen if you rented a scale for home use. It can be hard to judge a good feeding just based on feel alone. That's why the scale can be useful- if you're doing your own before-and-after weights, and you know exactly how much baby took in, you know whether you need to supplement and/or pump.

I would definitely rent the hospital-grade pump. I can't tell you what a difference it made for me in terms of output, compared to the Ameda Purely Yours I had been using previously. I know it's expensive, but in the long run it's cheaper than formula.

I would also really push forward on the thyroid angle. Low TSH suggests that you're hyperthyroid right now, and that might mean you need to throttle back on whatever thryoid replacement you're taking (levothyroxine, Synthroid, whatever). Having an out-of-whack thyroid can really impact supply, whether that means being hyper or hypo.

Re: Stuck in a rut, low supply/supplementing inefficient nur

Thank you for the reply! Regarding the thyroid levels, I should clarify. The TSH was low for me, the past few years it's been more in the 2.5-4 range and this time was 1.15 which is still within normal. I haven't been terribly happy about the treatment I've gotten though in the past so I'd like to see the specialist to get that straightened out.

As far as renting the pump, that makes sense in regards to the cost of formula if it does work to increase my supply. I'm probably being a negative Nancy at this point in assuming it won't make a difference, but I really should give it a go to see. About how long does it take to see an improvement?

Re: Stuck in a rut, low supply/supplementing inefficient nur

Originally Posted by @llli*rviolet

. About how long does it take to see an improvement?

Probably the hardest question to answer in the breastfeeding universe! It depends on so many factors- how fast do you respond to the pump, how much pumping are you able to do, does the pump you have work well for you, is there another factor in the mix that is damping down your supply... It's just too complicated for a one-size-fits-all answer. I personally had good results within a few days to a week- but I responded well to pumping and was able to pump 8-10 times a day.

Are you currently using hormonal contraception? That can put a damper on supply for some women...

Re: Stuck in a rut, low supply/supplementing inefficient nur

ok sorry, my baby kept stepping on keyboard and erasing my post. ergh. I did pm you, I hope you can call me or some other breastfeeding support person. You have a lot on your plate and it appears the current plan may need tweaking as you are not feeling confident or able to continue in it? Can you talk to your IBCLC about your feelings, concerns?

Mostly I have more questions, sorry.

How is weight gain now?

How many ounces of breastmik per day is baby being supplemented?
How many ounces of formula per day is baby being supplemented?

Is baby being supplemented with a bottle? Were alternatives discussed, particularly, a lactation aid?

If supplementing with bottles are you cue feeding, using paced bottle feeding with pauses, and supplementing small amounts at a time?

have you discussed galactagogues with your IBCLC?

What is happening when baby nurses? Are you nursing baby at earliest cues while baby is calm? Have you tried a variety of positions? Does nursing hurt or is it uncomfortable for you? Does baby have a hard time latching, or staying latched? When baby falls asleep while nursing, have you tried breast compressions and switching sides? Have you tried letting baby fall asleep, while holding baby, keep holding baby, and nursed again whenever baby rouses instead of supplementing right away? Have you tried skin to skin?

Of course you are worn put. Besides having a newborn, always exhausting even when all is well, you are also "triple feeding" -nursing, pumping, and then supplementing. But I see a real problem that the nursing part has taken such a back seat to the pumping and supplementing. Even IF baby is capable of taking ‘only’ an ounce at the breast, shouldn't baby be encouraged to do so, as often as possible, so baby can learn to nurse? An ounce is a normal feed. So is half an ounce. So is 3 ounces. (by this age.) Intake varies session to session and from baby to baby for a variety of reasons.

Re: Stuck in a rut, low supply/supplementing inefficient nur

Weight gain is good and has been since we began supplementing.

He's been eating a lot more the past couple of days - more around 4.5-4.75oz per feeding (previously was around 3.75oz), but he's about 11oz of breast milk in a day and 17oz formula since the increase. Before the bump up in amounts, it was a little less lopsided to the formula side. We did feed more frequently the past two days (and pumped more frequently) but my supply didn't increase to compensate from what I can see.

He is being supplemented with a bottle, we tried the SNS but found it rather cumbersome to get set up and at the time his latch wasn't so great when we tried it out. I did forget to mention that while his latch is improved, I think it's still a tad shallow. He always has a sucking blister, even when feeding from a bottle his upper lip gets tucked under. When feeding at the breast, I usually need to pop the upper and lower lip out. We have tried to only nurse when he's calm when we know he should be hungry but hasn't gotten frantic. We are comfortable with the cross cradle on the left side and football on the right. My breasts are large and very soft, so I need to support them when feeding him. In general, it's fairly comfortable now though sometimes when he pops off and relatches it's too shallow and painful so we need to adjust. Sometimes he grimaces and doesn't open his mouth widely and frantically tries to latch on. Once he's awake and ready to eat, he tends to shake his head back and forth quickly - does this with the bottle and breast. He quickly escalates to screaming if he doesn't latch right away. When he falls asleep, we use pumping his hands/feed, tickling his spine/ear/neck/tummy, I'll use compressions sometimes but he doesn't always swallow well when his mouth is full when waking up and coughs and sputters. I have tried letting him sleep, he'll wake and nurse a bit off and on but eventually he will unlatch himself and sleep for 10-15 minutes. I haven't done much skin to skin because I tend to get very hot and sweaty and can cause him to get overheated.

The reason it's a problem if he only takes an ounce is that he screams when he's hungry, even if he's eaten half a meal. While bottle feeding, even if he started the feeding calmly while taking any pauses or switching bottles, he screams. He screams while being burped if he hasn't been calmed down for some time after finishing his full meal. He's almost always screaming before, during and after a feed (he will calm down after 5+ minutes if he's screaming at the end of a feeding). I am definitely hesitant on a plan where he nurses and then just needs to wait until I have more milk for him.

Re: Stuck in a rut, low supply/supplementing inefficient nur

Do you have a LLL meeting or breastfeeding support group near you? One with many attendees? I think it might help you to see other breastfed newborns in action. Much of your baby's behavior sounds normal. Babies are compelled to suckle, and will often cry if they cannot. They also cry for many other reasons. Your baby is gaining well, and getting a normal amt of intake, (28 ounces per day plus whatever he gets when he nurses) so there is no reason to think he is starving or feeling so hungry he feels like he is starving. I would suggest, since baby gets frantic at eating times, perhaps when supplementing, feed smaller amounts more often, offer to nurse more often, and 'mix up' how you supplement-nurse first, nurse last, nurse on either side of the bottle, etc.

and I suggest, revisit the lactation aid. Maybe it was the wrong one for you. Maybe you needed to tape the tube to your breast or not tape the tube. Or insert tube after baby was latched or NOT do that. In other words, just like nursing in general, lactation aids take some fiddling. Here is more info -http://cwgenna.com/smartnothard.html

You might want to try laid back positioning, that may help with the frantic head shaking. And/Or sidelying

I have tried letting him sleep, he'll wake and nurse a bit off and on but eventually he will unlatch himself and sleep for 10-15 minutes.

this sounds normal to me. Am I missing something?

I haven't done much skin to skin because I tend to get very hot and sweaty and can cause him to get overheated.

I very much doubt your body heat is overheating your baby, (no hat! Those DO overheat babies) but if you are uncomfortable, try having baby in onesie and/or you have a tank or t-shirt on, and just snuggle baby on your chest, you relaxed-like on the couch, leaning back, baby snuggled tummy to you, with easy access to the breast should baby start to root. See the biological nurturing video below for an idea of what this looks like.

for low milk production I strongly suggest the book Making More Milk
stuff to try for latch etc-

Here are two simple pictorials, you want the one on latch. Notice that the mother is in a “slightly” laid back position, looks like on a couch? This is a very “adjustable” position, play around to find how you and your baby are most comfortable. http://cwgenna.com/quickhelp.html

Re: Stuck in a rut, low supply/supplementing inefficient nur

I will take a look at those articles. Thanks for the note about him overheating, I am admittedly nervous about him getting too hot because his temperature did elevate from me holding him in the hospital but he was bundled up. As far as his crying, in our range of things to try when he's crying we do offer a finger/knuckle/pacifier to suck instead of more food. When we've had nights where he never settled into any sleep longer than 15 minutes, I later figured out it was because he was still hungry. I've read countless articles about soothing fussy babies so we try everything I can think of but it's almost always narrowed down to him being hungry. We're not comfortable with cosleeping (due to AAP recommendations and personal feelings) so I'm not sure how we'd get any rest if he's needing to feed with that high level of frequency with my lack of supply? I'll also look into trying the SNS again, maybe it'll be easier now that we're having less difficulty latching.

I may not be altogether clear headed at the moment so I'll revisit this thread when I have gotten a bit more sleep.